A story I recently heard from an correspondent who works as a medical professional in a general surgery practice reminds me of the distance we have yet to travel in understanding even the seemingly obvious implications of drug abuse. My correspondent's practice sees a breadth of cases, including a diversity of acute trauma cases which are severe enough to require a surgery consult. Some cases will require immediate surgery and a lengthy hospitalization for recovery; several weeks may be required when someone has suffered severe trauma. Other cases might involve a little wait-and-see to determine if surgical intervention is going to be required; a several day observation window would not be uncommon. One of these latter cases resulted in an interesting story.
Agent: "We had a guy check himself out against medical advice while we were waiting to see if he was going to get better or require surgery. The patient was apparently really ticked off that they wouldn't let him out to smoke. He was found a couple of hours later lying in the street."
YHN: "So what happened, you mean he bled out or something?"
Agent: "Oh, no. In the Emergency Department they hit him with [the opiate antagonist] Narcan and he woke right up"

A lively conversation ensued. I learned a few things that surprised me.return to huntFirst, it turns out that it is not uncommon for smokers to be refused the opportunity to continue with their normal smoking practices when hospitalized for, say, an acute trauma. Even if the person is reasonably able to move to the outside smoking area for the requisite drug taking. This arises in some part from essentially "tut, tut" sorts of attitudes in the caregivers. As my discussant put it "they offer them the patch". As in the transdermal nicotine delivery device which comes in three doses (7, 14, 21). In this discussant's hospital, the 14 mg patch is what is offered to smokers with no regard for their smoking history. This patient under discussion was a more than one pack a day smoker which at the least would have recommended the highest patch dose. "Hmmmm" said I.
The nicotine patch is intended to be used as a canonical agonist therapy for tobacco dependence. Recall that agonist therapy is well described as "a weenie version of the real thing". In other words, the primary pharmacological effects are similar, the therapeutic drug is just less effective. In the case of the nicotine patch, since it is the same active compound, the "less effective" nature is conveyed by the slower rate of dermal absorption and eventual transfer of the drug into the brain relative to the smoking and buccal (oral tobacco preparations deliver drug though the gums) administration. The point being that the patch is not an effective replacement for nicotine smoking in the non-treatment-seeking individual. When someone gets into the hospital because of acute trauma, they aren't necessarily looking to stop smoking. They are likely nicotine dependent and will be going into some degree of withdrawal and drug craving if they are denied their usual smoking rate.
I see a big problem for proper medical care. One presumably wishes the patient to accept recommended care and if not, to make an entirely unfettered and informed choice to reject care. A drug addict who is being denied their drug of choice and is craving drug is not very likely to make such decisions uninfluenced, now are they?
Getting back to my little case study story, it turned out that nicotine dependence was only the start of the patient's drug problems. Which the medical staff knew because his tox panels came back all lit up for various drugs including cannabinoids and opiates. At least in this situation, nobody did anything with this information. "Anything" meaning anything along the lines of trying to determine how addicted he was, to which substances and making some fair guesses about withdrawal and other effects if he were to remain hospitalized for the intended duration to follow his trauma concerns.
So the patient checked himself out against vociferous medical advice. No duh! He was placed in withdrawal from multiple drugs of abuse, apparently including some variety of opiate addiction. Of course he wanted out. The end of the story, in which the patient was found unresponsive and was recovered by an opiate antagonist tells us the rest of the story. Dude went out to shoot up some heroin. Suggests the opiates on the tox screen should have been followed by a little investigation because with evidence of an active heroin addiction in hand, one might anticipate exactly the observed outcome, no?
Let us not overlook the general point, however. It could have been nicotine or cannabis or alcohol or any other drug withdrawal that modulated the patient's decision making with respect to accepting or rejecting recommended health care advice. I mean, "against vociferous medical advice" generally means along the lines of "Patient Doe, if you leave and the thing we have you hospitalized to evaluate actually occurs, you will die". One would think the expectation here is that patient's would be extended the right to refuse medical advice only so long as they were making a judgment in their right mind, so to speak. And only after being fully informed of the risks they run.
Can the withdrawing drug addict really be expected to make a decision that comports with a right-minded, informed consent? Really?
I think not and I think that there might be some interesting questions regarding medical ethics and liability should evidence of recent drug abuse be in the hands of the medical practitioners who then proceed to put the individual into withdrawal because of hospital practices. Particularly if the patient checks out of the hospital against medical advice.
Culprits? Well, doctors who are trained in med schools in a mindset that doesn't really appreciate the lasting motivational consequences of drug dependence certainly don't help. There is also the problem of parity when it comes to health insurance. I need to explore this a little more but my agent suggested looking at the phone numbers on the medical insurance card in my wallet. Sure enough, there is a separate number to call for mental health / drug dependence issues. It seems that primary care physicians are hamstrung when it comes to requesting specialist consultation for something like drug abuse. Perhaps this was the problem in my discussed example- that a positive tox screen for drugs cannot automatically result in the right expert being called in. Unlike a weird cardiac indication, for example, or evidence of some unusual tumor. I don't fully understand the issues yet. I'm already in favor of parity for drug abuse-related health concerns, natch, but this question of drug craving modulating decision making on the part of the patient seems like a very strong additional argument.

Clues to chemical dependency in hospitalized patients:
1. Recurrent or severe bronchitis in person with no known risk factor. This suggests crack cocaine use.
2. New onset of confusion, delirium, or agitation, especially 24-48 hrs after admission. Note that these symptoms are not psychosis, but often are mistaken for psychosis. This is a bad mistake to make. Especially if you don't think to give thiamine, and the person develops permanent brain damage.
3. Insisting on visits from friends, outside of regular visiting hours.
4. Phone calls at odd hours.
5. Typical symptoms of alcohol, benzodiazepine, or opioid withdrawal are good clues, but only if you know what the typical symptoms are.
Note that insurance companies do not limit what kind of specialist consultants can see a patient in a general hospital. However, in order for the consultation to be useful, it is helpful if the attending physician poses specific questions.

This arises in some part from essentially "tut, tut" sorts of attitudes in the caregivers.

There are other problems as well. If you give a patient permission to go down for a smoke, you are essentially saying that you think they are well enough to be unsupervised, since you can hardly spare a staff member to accompany every smoker. Then, when something bad happens to an unsupervised patient wandering around alone, you, as the MD/nurse/administrator are responsible.
we can't let them smoke in their rooms for obvious reasons, so addicts are basically screwed...they have to deal with being very uncomfortable (leading as you say to impaired decision making) which makes us even more responsible for watching them closely...

Assuming the medical team is suitably informed and motivated, is there something they could do for every addiction they would be likely to run into, or are there some drugs for which no prescribable analog exists? I'm assuming that just letting their dealer stop by isn't really an option in most situations.

PalMD@#2- Yeah, I know it's complicated. and Jeb@#4 is onto the same topic, as in "what do you do differently?" I mean, you probably aren't going to hook up on-demand IV morphine to an addict to keep 'em cool while you deal with some other health issue...or are you? smoking is a little easier, of course. I think in the situation I'm describing there is a little disconnect between the hospital practices and the surgical practice's preferences (which are more on the "let 'em smoke, we're not going to deal with that when we have an unrelated surgical situation at hand")
I guess my main concern would be that I think that the more obvious and acute withdrawal signs as outlined by Joseph@#1 are not the problem. Obviously when you have a patient mysteriously seizing or shaking or vomiting, etc, the medical folks rapidly arrive at "withdrawal" as one of the likely scenarios. It's the more subtle, motivational part that worries me.
phisrow@#3- depends what you mean by analog, of course. for most of the biggies you can get very close with something that is available for medical use. route of administration may be an issue (smoking crack or ice is probably right out, is what I'm saying....) but I think you can get just about anything in an injectable form if really needed clinically so you can get close with IV.

We have many different ways of managing things. We use nic patches, but as DM pointed out, these are imperfect. We use benzos to prevent alcohol withdrawal/DTs which can be deadly. We will use clonidine, and occasionally opiates to manage opiate withdrawal, but all of these measures are imperfect.
We offer psychiatric consultation.
The sad truth is, yes, addiction is a physical disease, but also a psychological one. We can't let a patient endanger themselves and others by regularly giving them smoking passes (besides the entire hospital campus is smoke free). Drug withdrawal is very, very uncomfortable, but some aspects of it are unavoidable. If a patient wants their medical condition fixed, they will have to put up with some of the discomfort. It sucks, but it's reality.

The sad truth is, yes, addiction is a physical disease, but also a psychological one.
c'mon now, if you want to troll me into my usual anti-MDdualism ranting you have to be a little more subtle than that!

I have actually dealt with this from the receiving end. I was extremely ill to the point that I had fractured four of my ribs from dry heaving. I had a close friend with me who had insisted that I come in because I couldn't hold down water and had become severely dehydrated. She was also a nurse who had once worked in the ER I was in, though she had since gone to work in a nursing home.
After I had been through all the tests and x-rays and the anti-nausea drugs and painkillers had really gotten to work, I was desperate for a cigarette. I was also feeling a whole lot better than I had. They really wanted me to stay the night, but were refusing to let me go smoke. The only way that they could let me out was if I was accompanied by a nurse, intern or doctor. The only reason I stayed was because the friend who had brought me convinced one of her old colleagues to take me with him on his next smoke break.
While I understand that it is not always possible for patients to step out for a few puffs, I don't see why more hospitals don't consider letting patients who aren't too bad off to step out with staff that are going to do the same thing. Not that this would be practicable at hospitals with totally smoke free campuses, but it would be at a lot of hospitals. I know this happens unofficially at a lot of hospitals, as I have overheard patients talking to their nurses about helping them find someone to take them out. I can't imagine that's isolated.
At the very least, consideration can be and should be taken. Nicotine inhalers can at least provide a better nic fix than patches or gum. Valium would help take the edge off for the heavier smokers or those who simply can't cope.
Tobacco withdrawal produces anxiety and agitation. This on top of being in a hospital, which for many of us (definitely me) also produces anxiety and agitation. Anxiety and agitation (or so I understand) can be impediments to the healing process. Recognizing and dealing with addictions would go a long ways toward helping patients get better (this of course applies to all addictions, I just used tobacco because I happen to suffer that particular addiction).
I would also note that I definitely feel like the attitude coming from most medical professionals on this issue, is that the addiction is just a bad thing so it just isn't worth bothering about. On the one hand, sure, the addiction is probably a very bad thing. It would be great if the patient wanted to get over the addiction and wanted you to help. The problem is that while most addicts probably recognize that addiction is a bad thing, many even recognize that their own addiction is a bad thing (if they recognize their addiction at all), we still have that damned addiction. The point when we are feeling the worse, whether through injury or illness, is not the time to shove a bunch of self-righteous, anti-addiction rhetoric up our bums.
When I was horribly dehydrated and just come off of twenty-eight ours of virtually non stop dryheaving, I didn't want a fucking lecture about smoking. I didn't want to have my rather serious (to me at that point) problem dismissed with an exasperated "you'll just have to cope!" I wanted a fucking cigarette. Short of that I would have accepted some basic sympathy, especially if followed by a "sorry I can't let you out, but maybe this nicotine gum/inhaler/patch might help." Being dismissed the way that I initially was, almost had me out of there anyways. Not simply because I wanted a smoke, but because my nurse had become quite bitchy after I brought up my desire to smoke. It was like I was suddenly a very bad person and didn't deserve her kindness and sympathy.
She got worse when my friend actually managed to get me an escort to go smoke.

DM, I guess you have a point about the dualism thing. Any time we deal with illnesses that appear to be more of mind than flesh, we get into all these murky issues, which I'm going to try to avoid.
The fact is, in a hospital, value judgements aside, it isn't practical to allow people to smoke. There are plenty of real world examples of patients wandering off and having "very bad things" happen. I certainly would allow my patients to bring in nic inhalers if their medical condition allowed. Of course, many conditions don't. Many patients are in the hospital for chronic lung disease, coronary artery disease, and peripheral vascular disease. Part of treating these is stopping smoking. Stopping smoking sucks. Still, it has to be done. The same goes for heroin, coke, EtOH, etc.
If I were to allow a patient with critical peripheral artery disease to smoke, I might as well just hand them a bone saw and say "go for it".

PalMD, I gotcha that medical professionals want people helped, have a limited window of opportunity and might want to address as much as possible in the time they see the patient. Particularly from an internal med perspective. But I was talking about pretty acute trauma stuff here that was not directly related (we can discuss trauma rates in the chronically intoxicated, but I think you can see what I mean) to the addiction.
Take DeWayne's point though. Getting into a patient's drug abuse habit when they really are there for something else compromises care of the something else if this motivates them to just bail from the hospital, no?Any time we deal with illnesses that appear to be more of mind than flesh, we get into all these murky issues, which I'm going to try to avoid.
The more I interact with (non-mental health / non-drug addiction expert) medical care providers on this issue, the more I realize that this is a BigFreakinProblem, not some murky, irrelevant semantic distinction. There is no such thing as the "mind" that is distinct from the "flesh". Period. The "mind" is most assuredly the reflection of the physical states of the brain. Just because we don't completely understand how this works does not make it magic, sky-fairy stuff.
It is precisely this sort of dismissive "it's just psychological addiction" crap that leads to patients refusing or avoiding medical care because they fear the drug cravings that will result if they are forcibly prevented from using and told that they should just deal with it.....

I have once again expressed myself poorly. There is a real danger in the dualist approach, but we are still stuck with behavior. Since we don't have perfect pharmacological approaches to this for inpatients (or outpatients for that matter), we are stuck providing what support we can. No, it doesn't address ANYTHING to say to someone "you're morally weak, just stop smoking", but you still have to say, "you must stop smoking or you will be disabled/dead. I have a few things to help you through it but it will suck. Good luck".

PalMD -
Personally, I am all for the "I'm sorry but your condition just can't allow us to let you go smoke, but we are going to do everything we can to make it easier on you," approach when it is necessary. The big problem that I have is with the pervasive "you made stupid choices, now deal with it you pansy," approach.
It's about how people with addictions are treated, not about catering to them exactly as they wish. It's about recognizing that no matter how foolish, vile or petty you might feel the addictions and behaviors that led to those addictions are, they are a real cause for suffering for a certain number of your patients. It's about understanding that for the patient in question, this is a very big, very serious problem.
At the same time, many health problems of addicts (no matter what the addiction) are going to be directly related to their addiction. This may well require a very different tact, or many different. I can see the value in making it crystal clear that without getting ahead of their addiction, if they cannot/will not stop, they will die. I would even argue that refusing to treat a related illness without a commitment from the patient to comply with orders for addiction treatment, might be called for in some cases.
But for patients who are not being treated for something related to their addiction, I think it's important to do what you can for them. Telling a smoker that you would like to help them quit is a lot more palatable when they know that you recognize this is a very big deal for them and are doing what you can to compensate, whether it's with an inhaler or seeing if a smoker on staff can't take them with them on a smoke break (again recognizing that on your campus that wouldn't work).
Short version; Don't dismiss the power that the expression of sympathy for the addicts plight can have on convincing them to stay put.
DM -There is no such thing as the "mind" that is distinct from the "flesh". Period. The "mind" is most assuredly the reflection of the physical states of the brain.
I am very much with you on this concept. In reality this is pretty absolute. On a near daily basis more evidence to support this comes to light through the hard work of neuroscientists. I make this same point on a regular basis, occasionally even in similar contexts.
But (and this is a rather big but) in practice our understanding of neuropsycology is still in it's infancy. We are not that many decades out from mind/body duality being the default assumption. Neuroscience is relatively young and extremely complicated. Knowing that the problem is ultimately physical is all fine and good, but it doesn't really lend itself to a solution right now. This isn't to say that I don't think the distinctions are important, they are. But that distinction doesn't currently have a lot of practical application outside of research that is lending itself to solutions.
Ultimately it's still murky and mysterious. It's much like the black plague was murky and mysterious as it wiped out vast swathes of European populations. Easy enough for us to know that it was microscopic organisms that were killing so many folks. Were you to tell people then that a tiny creature they couldn't even see was causing so much death, it wouldn't have been any less mysterious to them and without our current level of technology it would be of little use.
Take my smoking. There are many, many options on the market to help me with the more overt chemical dependency. Nicotine that comes in many forms. It's great, but it has never helped me quit, because there is a whole lot more to my addiction to tobacco, than mere chemical dependency to nicotine.
I smoked for months before I became chemically dependent. I would smoke one, then it might be two or three days before I had another. Mostly I smoked when I was hanging out with a certain group of friends who smoked. Second hand smoke made me really nauseous, which was alleviated when I had a cig myself. The thing is that I liked it. I really liked it.
Smoking became a much bigger thing for me when I left home, dropped out of school and went hitchiking around the U.S. Tobacco was the most stable aspect of my life during those years, when as often as not I slept out doors. I was pretty constantly on the go, a couple weeks being the longest I usually stayed in one place. I would regularly make runs that took me great distances, pretty much aimlessly, because I just wanted to see as much, as many places as I could. The one thing that remained consistent in my life was cigarettes.
I have generally been pretty much on the low end of the economic spectrum. Early in my tobacco use, I started rolling my own. I found that I could actually buy really tasty tobaccos for less than it cost to buy premades. Somewhere along the way it took on a hobbyist dimension, much like beer and wine hobbyists. I take a great deal of pleasure in affording myself this luxury, one of the few that I enjoy.
All of this is psychological and rooted in the physiological wiring of my brain. But there isn't a simple, physiological answer to these problems that help keep me smoking. There are pharmaceuticals that can help, but a cognitive approach is also called for. Indeed, a cognitive approach is an essential part of my fight against my addiction to tobacco.
In effect, recognizing that the psychological is physical isn't going to help much in this context. It doesn't change the need for cognitive approaches, nor does it change the fact that catering to patient addictions can simply be impossible. It is important in the development of new treatments, including cognitive approaches - I have no doubt that we are on the cusp of some major breakthroughs in treating mental dysfunctions. For that I think it is important to get people on track with the understanding that the mind is the body. But in practical terms the mind is still pretty damned mysterious and will continue to be such for most people, even as they accept that there really isn't a mind/body duality.

DeWayne, as always I read in awe. You have a gift for writing and a wealth of highly informative personal anecdotes to relate. It is really too bad that you don't know someone, like a close friend or relative or something like that, to get you hooked up with a scenario that might get you paid for writing.
I think I take you point which is focused on using whatever framework is effective for a given user to help them with discontinuation. I'm right there with you. If a MD had to use this lies-to-children with some patients, cool. What I fear is that the MDs themselves distinguish the so-called psychological from the physical in a way that leads them to minimize, dismiss and provide inferior care when the patient is "only" craving....

I think I take you point which is focused on using whatever framework is effective for a given user to help them with discontinuation. I'm right there with you. If a MD had to use this lies-to-children with some patients, cool.
This is a tough one to swallow and without some actual clinical experience (and Mrs. Juniorprof's clinical work) I don't think I would be able to stomach it. However, the simple fact is that patients have to be able to relate to their addiction or other problems in some real way and it is rare to find such patients that can fully understand that their mental processes are nothing more than patterns of neuronal firing and neurochemistry. In fact, it is my experience, mostly through communication with Mrs Juniorprof and clinical colleagues that most people cannot handle such approaches at all and reductionist talk (such as this) on the part of clinicians sends them into a spiral of hopelessness. The fact is that while information is paramount to helping patients recover, this information must be delivered with empathy for the background and coping ability of the patient.What I fear is that the MDs themselves distinguish the so-called psychological from the physical in a way that leads them to minimize, dismiss and provide inferior care when the patient is "only" craving
This scares me as well but it is useful to note that the system is so taxed (and the people so overworked) that in reality it is an unavoidable consequence of propping up a system that cannot function in a sustainable way anymore. Moreover, public hospitals, where these problems are endemic, have been disproportionately hit by the redistribution of funds in such a way that the good people that work there are frequently at wits end. The most frequent complaints I hear from Mrs Juniorprof never concern the difficulties of very complicated cases but deal with the limitations of time and her inability to take care of her patients up to her already high standard. It is sad to see people who truly love helping our fellow humans at their deepest and darkest hour consider dropping it all because they can no longer do their job up to their own expectations. These people, doctors, nurses and technicians, are rare birds and deserve better than that.
These are symptoms of a system on the verge of collapse. We would do well to think long and hard about them and strive to assist our clinical colleagues in any way possible to fight our way out of this mess.

What an interesting post and discussion. THanks for writing this-
In performing a root cause analysis on an unrelated problem for a hospitalized patient in a critical care unit who had previously undiagnosed/treated mental illness and symptomatology, I discovered that there are no national standards of nursing care and practice for patients with mental illness/addiction who are hospitalized in non-behavioural health inpatient settings (med/surg and critical care units). None.
I'd be interested in lerning whether medicine has standards of care and practice for these patients which specifically address their mental illness/addiction symptomatology.
The majority of hospital inpatient units aren't equipped with the resources and nurses with the clinical expertise to care for patients with dual needs. And most psychiatrists will not visit patients and initiate therapy until patients are "medically cleared".
Forty percent of all inpatient psychiatric beds in the US have been closed - largely due to abysmal reimbursement and free market forces. Over one half of all inpatient psychiatric care is delivered in prisons (this includes treatment for addictions).
The culture in hospital settings (non-behavioral health) is to just "get the patient out of here". There is no interest and skill, for the most part, in addressing addiction and dependence in real time.
Sicker, quicker - get 'em gone.

Annie, you make some fine points. I can speak for two public hospital ERs (in different states) which each had a psych nurse on call in the hospital for such needs. It was/is frequently not enough. There is a real shortage of funds and a real shortage of people with appropriate expertise. It does not help an already bad problem.

I can't say what a pleasure it is to read such a thoughtful thread on this issue. I wish more people were interested in having this kind of dialogue about objectively improving substance abuse treatment, without letting their personal biases get in the way.

Juniorprof -
I think you are hitting on another facet of what I was talking about. (please don't think I'm criticizing you, I am just using you as an illustration) The fact of the matter is that a large percentage of patients (possibly a majority) believe in a soul/body dichotomy that lends itself to believing in a mind/body dichotomy. More extreme religionists (thankfully a minority, though a sizable one) believe that mental dysfunction, including addiction are literally caused by Satan and his demons.
These are the people who (I suspect - looking into it) have better odds of success in a twelve-step or other higher power/religion based treatment program. To them their addiction is something that absolutely requires the help of their god or god concept to defeat.
I don't think it's necessary to act as though you believe as they do. I.e. telling them something like "thankfully you have god to help you through this" isn't needed. The same is true with saying things that imply you believe in a mind/body dichotomy. It is plenty to recognize what they believe and not to tell them they are wrong. Especially with the mind/body issue. It is remarkably easy for a lot of folks to accept that such a duality is possible, even as using drug therapies to deal with the underlying conditions in the brain can help with their problems. And if pressed into a conversation that attempts to pin you down, there's no reason not to tell them what you believe. It should be done delicately to be sure, but the ability to do that is part of what makes a great doctor great.
DM -What I fear is that the MDs themselves distinguish the so-called psychological from the physical in a way that leads them to minimize, dismiss and provide inferior care when the patient is "only" craving....
At the risk of sounding condescending (I'm not really, it's just that I do have something of a grasp of human nature) I tend to think that this is not so much a case of a doctor not distinguishing that the pschological is physical, as much as it is a case of said doctor) or other health care professional not knowing how to deal with it.
Ultimately though, I believe the problem tends to be that addiction related problems that are not life threatening tend to be dismissed by many doctors because of a distaste for people who disrespect their own bodies by using the drug they are addicted to. It is very hard for many people to grasp that something as simple as the beer or glass of wine that they can enjoy after a good dinner, is something so very different for an alcoholic. Unless a person has experienced first hand the ease with which addictions can take root, it is easy to disrespect addictions and those who have them. The notion that the same experimentation that a great many people delve into when they are younger, can lead others into very dark places is incomprehensible to a great many people.
On the flip side of that, I think there is also a certain percentage of folks who tend to recoil from addicts and thus can seem disrespectful, because of the "there but by the grace of (something) goes I" phenom.
Annie -
I had been tossing the notion that much of this thread could apply to many other mentally ill patients. Thanks for mentioning it, because I would tend to think that is just as much a problem as the rest.